Transradial versus transfemoral access for diagnostic cerebral angiography: a systematic review and meta-analysis of 32 studies

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Objective To compare the safety, efficacy, and patient-centered outcomes of transradial access (TRA) versus transfemoral access (TFA) in patients undergoing diagnostic cerebral angiography.Methods PubMed, Embase, and Scopus were searched from inception through April 2026. RCTs and observational studies comparing TRA with TFA for diagnostic cerebral angiography were included. Random-effects meta-analyses were performed using risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes with 95% confidence intervals.Results Thirty-two studies (18,953 patients) were included. TRA showed significantly lower total complications (RR 0.63,95% CI 0.43–0.93; p = 0.02), fewer minor complications (RR 0.39,95% CI 0.22–0.68;p = 0.0009), shorter hospital stay (SMD −0.78,95% CI − 1.50 to −0.07;p = 0.03), and reduced immobilization time (SMD −5.81,95% CI − 7.66 to −3.96; p < 0.01); major complications were comparable between groups (RR 0.27; p = 0.24). Overall diagnostic success was similar (RR 0.98,95% CI 0.96–1.00; p = 0.11), though RCTs alone showed significantly lower diagnostic success with TRA (RR 0.96,95% CI 0.93–0.99; p = 0.008). Crossover rates were significantly higher with TRA (RR 3.19,95% CI 1.62–6.28; p = 0.0008). Procedural duration, fluoroscopy time, contrast utilization, and radiation exposure did not differ significantly between groups (p = 0.20–0.89). Radial artery occlusion did not differ significantly between groups (RR 10.93,95% CI 0.50–236.74; p = 0.13).Discussion TRA was associated with fewer complications and faster post-procedural recovery while maintaining broadly comparable overall procedural outcomes. However, the higher crossover rate and modestly lower diagnostic success observed in randomized studies highlight important technical limitations. TRA should therefore be considered a reasonable alternative to TFA, with patient selection, operator experience, and institutional expertise influencing procedural success.